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The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information?
- A. Are you only able to breathe when you are sitting upright?
- B. How far can you walk without becoming short of breath?
- C. Are you coughing up blood at night?
- D. Are you urinating excessively at night?
Correct Answer: A
Rationale: To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague.
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A client diagnosed with heart failure has been admitted to the ICU prior to invasive treatment. What treatment could be considered curative for this client?
- A. Cardiomyoplasty
- B. External pacemaker placement
- C. Surgical ventricular restoration
- D. Ventricular assist device
Correct Answer: C
Rationale: A procedure known as surgical ventricular restoration (SVR) decreases the size of the heart to a near normal size and shape by removing dysfunctional heart muscle that does not contract properly. Once the adynamic (nonfunctioning) area is removed, the ventricle is repaired with a patch. In the cases that were studied, 91% were free of congestive heart failure after surgery with an ejection fraction that increased from 30% to 40%. A cardiomyoplasty, placement of an external pacemaker, or a ventricular assist device are not considered curative for heart failure.
A client is scheduled for a multiple gated acquisition (MUGA) scan the following day. What medication is contraindicated for the nurse to administer the morning of the procedure?
- A. Furosemide
- B. Acetaminophen
- C. Morphine sulfate
- D. Guaifenesin
Correct Answer: A
Rationale: Diuretics are contraindicated the morning of a test to avoid any interruptions for urination. Clients are also medicated to relieve a cough that may cause movement during the test so administration of guaifenesin is not contraindicated. Acetaminophen and morphine sulfate are not contraindicated the morning of the test.
The nurse is preparing to administer digoxin to a client with heart failure. The nurse obtains an apical pulse rate for 1 minute and determines a rate of 52 beats/minute. What is the first action by the nurse?
- A. Administer the medication and inform the charge nurse about the rate.
- B. Withhold the medication and notify the health care provider of the heart rate.
- C. Administer atropine to speed the heart rate and then administer the digoxin.
- D. Administer the medications and then notify the health care provider.
Correct Answer: B
Rationale: Digitalis drugs are withheld if the heart rate is less than 60 or more than 120 beats/minute until a health care provider is consulted. The other choices would have the nurse administer the drug, which would not be the standard of practice.
A client with right-sided heart failure is admitted to the medical-surgical unit. What information obtained from the client may indicate the presence of edema?
- A. The client says that he has been urinating less frequently at night.
- B. The client says he has been hungry in the evening.
- C. The client says his rings have become tight and are difficult to remove.
- D. The client says he is short of breath when ambulating.
Correct Answer: C
Rationale: Clients may observe that rings, shoes, or clothing have become tight. The client would most likely be urinating more frequently in the evening. Accumulation of blood in abdominal organs may cause anorexia, nausea, flatulence, and a decrease in hunger. Shortness of breath with ambulation would occur most often in left-sided heart failure.
The nurse documents pitting edema in the bilateral lower extremities of the client. What does this documentation mean?
- A. There is excess fluid volume in the interstitial space in areas affected by gravity.
- B. There is excess fluid volume in the venous system of the lower extremities.
- C. There is excess fluid volume in the arterial system of the lower extremities.
- D. There is excess fluid volume in the hepatic system.
Correct Answer: A
Rationale: Dependent pitting edema (excess fluid volume in the interstitial space in body areas affected by gravity) in the feet and ankles can be observed. This type of edema may seem to disappear overnight but really is temporarily redistributed by gravity to other tissues, such as the sacral area. The other options are not descriptive of pitting edema.